APPLY FOR SURGERY Fill out our Medical Form to see if you’re eligible for a discount to undergo Gastric Sleeve surgery by April 2023. Download our Pre-Surgery Questionnaire Descargue nuestro Cuestionario Pre-Operativo Please Fill out and e-mail back or give to the Doctor BEFORE surgery. This is helpful info for the doctor to have, especially if you have any other medical problems. You always want your surgeon to be well-informed Procedure —Please choose an option—Lap BandGastric BypassGastric SleeveFillDuodenal SwitchBalloonPlastic Surgery Patient Facilitator Name Your Name Age Email Height Weight BMI Street Address City State/Province/Region Postal / Zip Code Country Phone (Home) Phone (Cell) I agree to receive SMS based on my data YesNo Maximum Weight When? List ALL Medicine Allergies Date of Birth Date of Surgery Name of person to contact in case of emergency Emergency Phone ----------------------------- Any Medical/physical problems (i.e., sleep apnea, high blood pressure, diabetes, high cholesterol, blood diseases, neurological disorders, etc)? YesNoDon't Know If Yes please list Are you currently taking any medications or herbal supplements? YesNoDon't Know If Yes, please list the name, dosage and reason for this medicine Is there any history in your family of diabetes, cancer and/or hypertension? YesNoDon't Know If Yes, please indicate which ones Any surgeries (i.e., gallbladder, appendix, hernia, heart, etc.)? YesNoDon't Know If Yes, please list Do you have any adverse reaction to anesthesia? YesNoDon't Know If Yes, please indicate the reaction Do you have dentures, dental implants, or caps? YesNoDon't Know If Yes, please indicate where Do you have any children? YesNo If so, how many? Do you have heavy periods? YesNo Do you smoke cigarettes? YesNo If so, how many cigarettes a day? Do you drink? YesNo If so, how many drinks? Do you do drugs? YesNo If so, what kind and how often? ----------------------------- Pre-Operative Assessment Patient Name Patient Age Patient Sex MaleFemale Date ----------------------------- For the Following Questions, Please Indicate "Yes" "No" or "Do Not Know". Please answer all of the questions. 1. Do you currently take any of the following medications? a) Aspirin (excedrin, anacin, bufferin)? YesNoDo Not Know b) Anticoagulants (blood-thinning medicine) YesNoDo Not Know c) Propanol, Verapamil (heart rhythm medicines) YesNoDo Not Know d) Diuretics (water pills) YesNoDo Not Know e) Antihypertensive drugs (blood pressure pills) YesNoDo Not Know f) Digitalis (heart pills) YesNoDo Not Know g) Steroids (prednisone, cortisone) YesNoDo Not Know 2. Have you ever been treated for cancer with chemotherapy or radiation therapy? YesNoDon't Know If Yes, when? 3. Do you currently have any problems with your: a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)? YesNoDo Not Know b) Kidneys (infection, stones, failure) YesNoDo Not Know c) Spleen YesNoDo Not Know d) Blood (anemia, leukemia) YesNoDo Not Know 4. Have you or anyone in your family ever had a serious bleeding problem? YesNoDo Not Know 5. Have you ever had prolonged or unusual bleeding from tooth extractions, cut, surgery or nosebleed? YesNoDo Not Know 6. Do your gums bleed when you brush your teeth? YesNoDo Not Know 7. Are you pregnant? YesNoDo Not Know 8. Is there any possibility that you are pregnant? YesNoDo Not Know 9. Have been told you have diabetes? YesNoDo Not Know 10. Do you wake up to urinate more than once at night? YesNoDo Not Know 11. Do you have muscle cramps or pains? YesNoDo Not Know 12. Do you have problems with your lungs or chest? (e.g., chest pain, skipped heart beats, high blood pressure, smoke one or more packs a day,(1) YesNoDon't Know shortness of breath, emphysema, asthma, bronchitis) if yes please list: 13. Do you have a cough, or cough frequently? YesNoDo Not Know 14. Do you have epilepsy or suffer from fits or seizures? YesNoDo Not Know 15. Do you have neck or back problems? YesNoDo Not Know 16. Are you scheduled to have an operation? YesNoDon't Know If Yes, what operation? 17. Are you currently taking any medications? YesNoDon't Know If Yes, please list medications: ----------------------------- The recommended surgery for obese patients with GERD or severe acid reflux is the Gastric Bypass. The bypass is the anti reflux surgery for weight loss. The sleeve can actually cause more reflux that may or may not be controlled with medication. In the case that the reflux is not controlled by medication you will need to consider converting your sleeve into a gastric bypass to prevent serious repercussions from the acids If yes, please write referrer's name By clicking SUBMIT, you agree to receive marketing text messages at the phone number provided. Reply STOP to cancel. Msg rates may apply.
